Opinions on Deepening the Reform of the Medical Security System

Central Committee of the Communist Party of China State Council

Opinions on Deepening the Reform of the Medical Security System

Medical security is an important institutional arrangement to reduce the burden of medical treatment for the masses, improve people's livelihood and well-being, and maintain social harmony and stability. The Party Central Committee and the State Council attach great importance to people's health and have established a basic medical security system covering the whole people. Since the 18th National Congress of the Communist Party of China, the reform of the national medical security system has continued to advance, and breakthroughs have been made in solving the problem of difficult and expensive medical treatment. In order to thoroughly implement the decision-making deployment of the 19th National Congress of the Communist Party of China on comprehensively establishing a medical security system with Chinese characteristics, and focus on solving the problem of unbalanced and insufficient medical security development, the following opinions on deepening the reform of the medical security system are hereby offered.

1. General requirements

(1) Guiding ideology. Guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 19th National Congress of the Communist Party of China and the Second, Third, and Fourth Plenary Sessions of the 19th Central Committee, adhere to the people's health as the center, and accelerate the construction of urban and rural areas that cover the whole people, coordinate urban and rural areas, and have powers and responsibilities. A clear, moderately guaranteed, and sustainable multi-level medical security system. Through unifying the system, improving policies, improving mechanisms, and improving services, the fairness and coordination of medical security will be enhanced, and the strategic purchase role of medical insurance funds will be used to promote medical security and medicine. Serve high-quality coordinated development, promote the implementation of the Healthy China strategy, and make the people have a greater sense of gain, happiness, and security.

(2) Basic principles. Adhere to the principle of providing all the medical insurance that should be covered and guaranteeing the basics. Basic medical insurance covers the whole people in accordance with the law. Adhere to stability and sustainability, prevent risks, scientifically determine the level of fundraising, balance the payment responsibilities of all parties, and strengthen overall coordination to ensure the sustainability of the fund. Adhere to the promotion of fairness, build a solid bottom line, strengthen institutional fairness, gradually narrow the gap in treatment, and strengthen basic and basic guarantees for the poor. Adhere to governance innovation, improve quality and efficiency, give full play to the decisive role of the market, better play the role of the government, and improve the socialization, rule of law, standardization, and intelligence of medical insurance governance. Adhere to system integration, coordination and efficiency, enhance the integrity, systematization, and coordination of medical insurance, medical care, and medical linkage reforms, and ensure that the masses receive high-quality, efficient, and affordable medical services.

(3) Reform and development goals. By 2025, the medical security system will be more mature and finalized, and the reform tasks of important mechanisms such as benefit security, financing operation, medical insurance payment, and fund supervision, as well as key areas such as medical service supply and medical insurance management services will be basically completed. By 2030, a medical security system with basic medical insurance as the main body, medical assistance as the backing, supplementary medical insurance, commercial health insurance, charitable donations, and medical mutual assistance will be fully established, with fair and moderate treatment guarantees and stable and continuous fund operations. Management services are optimized and convenient, and the modernization level of medical insurance management has been significantly improved to achieve the goal of better guaranteeing medical care.

2. Improving the Fair and Moderate Treatment Guarantee Mechanism

Fair and moderate treatment protection is an inherent requirement for improving people's health and well-being. It is necessary to promote the maturity and finalization of the statutory medical security system, improve the medical insurance and assistance system for serious and serious diseases, coordinate the high-quality development of various medical security, and steadily improve the level of medical security according to the level of economic development and the affordability of funds.

(4) Improve the basic medical insurance system. Adhere to and improve the basic medical insurance system and policy system that covers the whole people and participates in accordance with the law. Employees and urban and rural residents are classified into guarantees, benefits are linked to payment, and funds are established and accounted for separately. Unify the overall planning level of basic medical insurance and the medical insurance catalog, and standardize the determination methods of medical insurance payment policies. Gradually include outpatient medical expenses in the payment scope of the basic medical insurance pooling fund, reform the individual accounts of employees' basic medical insurance, and establish and improve the mutual aid guarantee mechanism for outpatient services.

(5) Implement a list system of medical security benefits. Establish and improve the medical security benefit list system, standardize government decision-making authority, scientifically define basic systems, basic policies, fund payment items and standards, and promote the legalization of the medical security system, scientific decision-making, and standardized management. All regions must ensure the smooth flow of government orders, and no policies beyond the scope of authorization of the list shall be introduced without approval. Strictly implement the basic payment scope and standards, implement fair and moderate guarantees, and correct the problems of excessive guarantees and insufficient guarantees.

(6) Improve a unified and standardized medical assistance system. Establish a timely and accurate identification mechanism for rescue targets, and scientifically determine the scope of assistance. Fully implement the policy of subsidizing key aid recipients to participate in insurance and pay fees, and improve the medical assistance mechanism for key aid recipients. Establish a long-term mechanism to prevent and resolve poverty and return to poverty due to illness. Strengthen the support function of medical assistance, reduce medical costs through measures such as clear diagnosis and treatment plans and standardized referrals, increase the annual medical assistance limit, and reasonably control the proportion of out-of-pocket expenses within the policy scope of the poor.

(7) Improve the guarantee mechanism for medical treatment expenses for major epidemics. In emergencies such as outbreaks of epidemics, ensure that medical institutions treat first and charge later. Improve the medical insurance payment policy for medical treatment of major epidemics, improve the direct settlement system for medical treatment in different places, and ensure that patients will not be affected by medical expenses. Explore the establishment of an exemption system for medical expenses for special groups and specific diseases, and specifically exempt restrictive clauses such as medical insurance catalogues, payment limits, and dosages of medicines, so as to alleviate the worries of poor people in seeking medical treatment. Coordinate the use of medical security funds and public health service funds, increase the proportion of payments to grassroots medical institutions, and achieve effective connection between public health services and medical services.

(8) Promote the development of a multi-level medical security system. Strengthen the triple protection functions of basic medical insurance, serious illness insurance and medical assistance, promote the complementary connection of various medical insurance, and improve the protection level of serious diseases and multiple medical needs. Improve and standardize the critical illness insurance for residents, large medical expense subsidies for employees, medical subsidies for civil servants, and supplementary medical insurance for enterprises. Accelerate the development of commercial health insurance, enrich the supply of health insurance products, make full use of individual income tax policies for commercial health insurance, and study and expand the scope of insurance products. Strengthen the supervision of market behavior, highlight the supervision of key links such as health insurance product design, sales, and compensation, and improve the ability of health protection services. Encourage social charitable donations, coordinate and mobilize charitable medical assistance forces, and support the orderly development of medical mutual aid. Explore the guarantee mechanism for rare disease drugs.

3. Improve the stable and sustainable financing operation mechanism

Reasonable financing and stable operation are the basic guarantees for the sustainability of the medical security system. It is necessary to establish a financing mechanism that adapts to the basic national conditions in the primary stage of socialism, matches the affordability of all parties, and coordinates with basic health needs, effectively strengthens fund operation management, strengthens risk warnings, and resolutely holds the bottom line of preventing systemic risks.

(9) Improve the financing sharing and adjustment mechanism. Employees participating in the basic medical insurance shall be jointly paid by the employer and the individual. The basic medical insurance for non-employees is paid by individuals, and the government provides subsidies according to regulations. The payment is linked to the level of economic and social development and the per capita disposable income of residents. To adapt to the development of new business models, improve the insurance payment methods for flexible employees. Establish a basic medical insurance benchmark rate system, standardize the payment base policy, reasonably determine the rate, and implement dynamic adjustments. Balance the financing and payment responsibilities of individuals, employers, and the government, optimize the structure of individual payment and government subsidies, and study multi-channel financing policies to deal with the medical burden of aging. Strengthen fiscal investment in medical assistance and expand financing channels for medical assistance.

(10) Consolidate and improve the level of overall planning. In accordance with the standards of unified system and policy, unified fund collection and expenditure, and integrated management and services, we will fully implement the city-level overall planning of basic medical insurance. Explore and promote the vertical management of medical security departments below the municipal level. Encourage qualified provinces (autonomous regions, municipalities directly under the Central Government) to promote provincial-level overall planning in accordance with the ideas of hierarchical management, shared responsibility, overall planning and adjustment, and budget assessment. Strengthen the management of medical aid funds, promote the coordination of the overall level of medical aid and basic medical insurance, improve the efficiency of the use of aid funds, and maximize the benefits of the poor.

(11) Strengthening fund budget management and risk warning. Scientifically formulate the budget of medical security fund income and expenditure, strengthen the supervision of budget implementation, and fully implement budget performance management. Adapt to the needs of direct settlement for medical treatment in different places, "Internet + medical care" and the development of medical institution service models, and explore the pilot project of cross-regional fund budgets. Strengthen the fund's medium and long-term actuarial calculations, build a balance of revenue and expenditure mechanism, and improve the fund operation risk assessment and early warning mechanism.

4. Establish an effective and efficient medical insurance payment mechanism

Medical insurance payment is a key mechanism to ensure that the masses can obtain high-quality medical services and improve the efficiency of fund use. It is necessary to focus on clinical needs, reasonable diagnosis and treatment, and appropriate technology, improve the medical insurance catalog, agreement, and settlement management, implement more efficient medical insurance payment, better protect the rights and interests of insured persons, and strengthen the incentive and restraint effect of medical insurance on the medical service field.

(12) Improve the dynamic adjustment mechanism of the medical insurance catalog. Based on the fund's affordability, adapt to the basic medical needs of the masses and the progress of clinical technology, adjust and optimize the medical insurance catalog, include drugs, diagnosis and treatment items, and medical consumables with high clinical value and excellent economic evaluation into the scope of medical insurance payment, and standardize the scope of payment for medical service facilities. Improve the dynamic adjustment mechanism of the medical insurance catalog, and improve the medical insurance access negotiation system. Rationally divide the central and local catalog adjustment responsibilities and authorities, and each region is not allowed to formulate catalogs or adjust the limited payment scope of medical insurance drugs on its own, and gradually realize the basic unification of the national medical insurance drug coverage. Establish evaluation rules and index systems for medical insurance drugs, diagnosis and treatment items, and medical consumables, and improve the exit mechanism.

(13) Innovate in the management of medical insurance agreements. Improve the management of basic medical insurance agreements, simplify and optimize the procedures for designated application, professional evaluation, and negotiation and negotiation by medical institutions. Incorporate qualified medical institutions into the scope of medical insurance agreement management, and support the development of new service models such as "Internet + medical care". Establish and improve the management mechanism of cross-regional medical agreement. Formulate assessment methods for designated medical institutions to perform agreements, highlight code of conduct, service quality, and cost control assessment and evaluation, and improve the exit mechanism for designated medical institutions.

(14) Continue to promote the reform of medical insurance payment methods. Improve the total budget method of the medical insurance fund, improve the consultation and negotiation mechanism between the medical security agency and the medical institution, promote the collective negotiation of the medical institution, scientifically formulate the total budget, and link it with the quality of medical care and the results of the performance evaluation of the agreement. Vigorously promote the application of big data, implement a multi-component medical insurance payment method based on payment by disease type, promote payment by groups related to disease diagnosis, pay for long-term hospitalization such as medical rehabilitation and chronic mental illness by bed day, and pay by person for outpatient special chronic diseases . Explore separate payments for medical services and medicines. Adapt to the development and innovation of the medical service model, and improve the payment method and settlement management mechanism of the medical insurance fund. Explore the implementation of total payment for close medical consortiums, strengthen supervision and assessment, retain surplus, and share reasonable overspending. Areas with conditions can prepay part of the medical insurance funds to medical institutions according to the agreement to ease the pressure on their fund operations.

V. Improve a strict and powerful fund supervision mechanism

The medical security fund is the "life insurance money" of the people, and the maintenance of the fund's safety must always be the top priority. It is necessary to tightly tighten the institutional cage for the supervision of medical insurance funds, focus on promoting the reform of the regulatory system, establish and improve the medical insurance credit management system, and severely crack down on fraudulent insurance fraud with a zero-tolerance attitude to ensure that funds are safe, efficient, and rationally used.

(15) Reform and improve the medical insurance fund supervision system. Strengthen the capacity building of medical insurance fund supervision, further improve the fund supervision system and mechanism, effectively maintain the safety of funds, and improve the efficiency of fund use. Strengthen the construction of internal control institutions of medical security public service institutions, and implement the responsibilities of agreement management, cost monitoring, and inspection and review. Implement cross-departmental coordinated supervision, actively introduce third-party supervision forces, and strengthen social supervision.

(16) Improve the supervision method of innovation funds. Establish a regular mechanism for supervision and inspection, and implement real-time dynamic intelligent monitoring of big data. Improve the monitoring mechanism for medical services, establish a mandatory information disclosure system, and disclose information such as medical expenses and expense structures to the public in accordance with laws and regulations. Implement the performance management of the whole process of fund operation, and establish a performance evaluation system for medical insurance funds. Improve the social supervision and incentive mechanism for medical security, and improve the reward system for reporting fraud and insurance fraud.

(17) Investigate liability for fraudulent insurance fraud in accordance with the law. Formulate and improve laws and regulations related to the supervision of medical insurance funds, standardize supervision authority, procedures, punishment standards, etc., and promote law-based and law-based administration. Establish a medical insurance credit system, and implement joint incentives for trustworthiness and joint punishment for dishonesty. Strengthen the joint law enforcement of departments, comprehensively use agreements, administrative, judicial and other means, seriously investigate the responsibility of fraudulent insurance units and individuals, and pursue criminal responsibility for suspected crimes in accordance with the law, and resolutely crack down on fraudulent insurance fraud that endangers the rights and interests of insured people.

6. Coordinated promotion of supply-side reform of medical services

The supply of medical services is related to the realization of people's health and medical security functions. It is necessary to give full play to the leading role of centralized procurement of drugs and medical consumables in deepening the supply-side reform of medical services, promote the integration of medical insurance, medical care, and medical linkage reform systems, strengthen policy and management coordination, and ensure that the masses receive high-quality and affordable medical services.

(18) Deepen the reform of the centralized procurement system for medicines and medical consumables. Adhere to the integration of recruitment and procurement, linking quantity and price, and comprehensively implement centralized procurement of medicines and medical consumables. Based on medical insurance payment, establish a provincial-level bidding and procurement platform integrating bidding, procurement, transaction, settlement, and supervision, promote the construction of regional and national alliance procurement mechanisms, and form a supply guarantee system with sufficient competition, reasonable prices, and orderly regulation . Promote the direct settlement between medical insurance funds and pharmaceutical companies, and improve the coordination mechanism between medical insurance payment standards and centralized procurement prices.

(19) Improve the price formation mechanism for medical services. Establish a market-oriented price formation mechanism for drugs and medical consumables, and establish a national transaction price information sharing mechanism. Control the inflated prices of drugs and high-value medical consumables. Improve the medical service project access system, speed up the review of new medical service price items, establish a scientific price determination and dynamic adjustment mechanism, and continue to optimize the medical service price structure. Establish a monitoring and disclosure mechanism for drug price information and industrial development index, establish a credit evaluation system for drug prices and recruitment, and improve the price inquiry and interview system.

(20) Enhance the accessibility of medical services. Improve the modern medical service system with the cooperation and division of labor between general practice and specialized medical services, and strengthen primary general medical services. Strengthen the evaluation of regional medical service capabilities, rationally plan the distribution of various medical resources, promote the sharing and utilization of resources, accelerate the development of social medical services, and standardize the development of new service models such as "Internet + medical care". Improve the allocation and management of medical equipment in regional public hospitals, guide reasonable allocation, and strictly control excessive equipment. Make up for shortages in medical services such as nursing, pediatrics, geriatrics, and psychiatry. Do a good job in the acceptance and review of generic drug quality and efficacy consistency evaluation, and support the development and use of high-quality generic drugs by improving medical insurance payment standards and drug bidding and procurement mechanisms, and promote generic drug substitution. Improve the monitoring, early warning and graded response system for shortage of drugs.

(21) Promote the improvement of medical service capabilities. Standardize the diagnosis and treatment behavior of medical institutions and medical personnel, implement a prescription review system, and promote rational drug use. Strengthen the internal professional and refined management of medical institutions, improve the scientific and reasonable assessment and evaluation system by classification, and link the assessment results with the payment of medical insurance funds. Reform the current department and individual accounting methods,